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Questions 149

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Question 1 of 5

A 22-year-old female primigravida who is at 36 weeks' gestation is seen in the ED with a low platelet count, ALT of 68 U/L, AST of 55 U/L, and a continuous, severe headache that has lasted three days. The nurse prepares for what to occur?

Correct Answer: C

Rationale: The symptoms suggest HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), a medical emergency requiring prompt delivery of the baby.

Question 2 of 5

The nurse assesses the development of a three-month-old boy in the well-baby clinic. Which of the following behaviors, if observed by the nurse, would be UNEXPECTED?

Correct Answer: B

Rationale: unexpected until 6 months of age

Question 3 of 5

The nurse is educating the lady's club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence.

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Correct Answer: A

Rationale: The Tail of Spence is the upper outer quadrant of the breast, where an X should be placed, as most breast cancers occur in this area.

Question 4 of 5

The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

Correct Answer: B

Rationale: Suspected falsification of records warrants a formal reprimand and investigation, but immediate termination or legal action requires further evidence.

Question 5 of 5

The primary physiological alteration in the development of asthma is:

Correct Answer: D

Rationale: Bronchiolar smooth muscle spasm is the primary physiological alteration in asthma, leading to airway narrowing.

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